HomeMy WebLinkAboutWYNTER PARK #1 BLK 1 LT 41Wynter Park
Block
Lot 41
#051 -491 - 12
Municipality of Anchorage '~:'
Developmen! Services Department
Building Safely Division
On-Site Wale~r and Waslewaler Program, 4700 S. Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650 Page
wvnv. cl.anchorage.ak.us (907) 343.7904
ON-SITE WAS?EWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Permit Number: ,.~['~ C~[(~/"~' VIDNumber:
"-/..I;-f>-F Hc.~3e,', NastewaterSystem: [-1New ~Upgrade
I~'~1 lal~.E~//ve, KIbJV ~'~J4a/loc6., ~)/~ O~ .~;~;~)o~Z~O~ ABSORPTION FIELD
'~ "~ '~ "~'~" I.[+
.. 51'+~' ~'=
Well: ~ New ~ Upgrade ~'~ ~,
SEPARATION DISTANCES ~ Septic D tlording D S.T.E.P. D
Tank Field Station Tank S~ [~e ~1 g~ ~
,~_w.. I~', I00~ ~/ UFTSTA~ON
~5~ 'H~ p~~ o~ BENCH MARK
· & ~ ENG;NEERING
~o~.~,,~.. c~,~,.~,~..~..~ : ~" ~-~-ol ,~, ...............
Inspections per fo
Develbpme~t Se~lces Department Approval
Reviewed and approved by: ~~ ~ - ate: Jo -/~-~ / Ct I~'.'<~'~'.~""';. .......
P£m.T NO $W010334 PACE 2 OP 3
P ........ M u_ni_c ip. g_[i .t y_o. ,F .A.n_c h.o r ag.e.
b~A~/M~N/ Oh M~AL/M AND HUMAN SERVICES
ENVIRONHENTAL SERVICES DIVISION
P.O. Box 196650 $Anchoroge, At~sk~ 99519-6650ITetephone~ 343-4744
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
~cAL LOT 41~ BLOCK 1~ WYNTER PARK ~1 P.LD. NO. 051-491-12
_ SEPTIC"~
AREA ~....-'"'---"-'-.--~
/
s~: ~' I ~o' j
~ ~ / 1.~ ",.,'~,~
.... : ......
~ ~ ~ ROBERT ~ COWAN
h'~ ..~
· ~C~-/R'.- ......... :::, c- ..-
· ~4. :~ ',
P£R,~IT NO $W010~34 PAGE 3 OF' 3
Municip. atilt_ _ _y_..o¢ .A.n_c h.o.r'o.g.e.
DEPARTMENT OF HEALTHAND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 eAnchor~ge, Al(lsk~ 99519-6650 ~ Telephone, 343-4744
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
LEGAl. LOT 41, BLOCK 1, WYNTER PARK #1 P.I.D. NO. 051--491--12
A B
FCO 6.5' 22.0'
ST1 12.0' 22.5'
ST2 14.5' 20.0'
DBL1 16.5' 18.5'
DBL2 17.5' 18.5'
DV 18.5' 18.0'
FS 16.5' 26.0'
C01 20.0' 28.5'
C02 44.0' 50.5'
C03 13.0' 34.0'
C04 61.0' 69.5'
MT1 23.5' .~0.5'
MT2 16.5' :]6.5'
FINAL GRADE/
MT1-85- .6'j
ST1 ST2 /-96.2'
FINAL
91.6TMJ ~,~v~v~:; J '
~-91,4
CO1 =96.4'
02=96.1'
MT2=85.5'j
·
NO WATER FOUND
78.5' B.O.H.
MUNICIPALITY OF ANCHORAGE
Development Services Department
On-Site Water & Wastewater Program
4700 South Bragaw Street
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
Upgrade
Date Issued: Aug 23, 2001
Expiration Date: Aug 23, 2002
Permit Number: SW010334
[Legal Description: WYNTER PARK #1 BLK I LT 41
Design Engineer: 0003 S & S Engineering
Owner Name: Cliff Hansen
Owner Address: 15901 121STAVENUE KPN
GIG HARBOR, WA 98329-0000
Parcel ID: 051-491-12
Site Address: 021138 LOOKOUT CIR
Lot Size: 24586 SQ. FT.
Total Bedrooms: 3 Permit Bedrooms: 3
This permit is for the construction of:
[] Disposal Field [] Septic Tank [] Holding Tank [] Privy
[] Private Well [] Water Storage
All construction must be in accordance with:
1. The attached approved design.
2. Ail requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations ( 18AAC72 ) and Drinking Water Regulations ( 18AAC80 ).
3. The engineer must notify DSD at least 2 hours prior to each inspection. Provide notification by caIling
(907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either: A. Open and closed on the same day.
B. Covered, sealed, and heated to prevent freezing.
Received By:
Issued By:
Date: ~-3.V-.o/,
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
wvw.cl.anchorage.ak.us
(907) 3,43-7904
ON-SITE SEWER/VVELL PERMIT APPLICATION
FOR ,b, SINGLE FAMILY DWELLING
Permit Number SW O I O ~.~
Propertyowner(s) ~/,"~-Y Ho,,5~,~ Dayph°neh
Mailing address (1) ~l! J ~ Loo~og~ C/~c~ ~ ~flaG~A~/A~ qo~6 7
Mailing address (2) Zip Code
Legaldescription(Lot, Block& Sub'd.) ~0~ ~1~ ~DE~ ~1 ~D~F
Legal description (Section. Township & Range)
Lot Size ~ 5 ~ Acre~' ' Number of Bedrooms ~
THIS APPLICATION IS FOR:
Sewer Only
Sewer and Well
Sewer Upgrade
THIS PROPERTY CONTAINS:
Hot Tub
Swimming Pool
Therapy Pool
Well Only
Water Storage
Water Softening Unit
I certify that the above Inl'ormaUon Is correct. I further certify that this application is being made for a
Slngle Family Dw~lllng and Is In accordance with applicable Municipal Codes,
S & $ ENGINEERING
Eaqle River~ Alm~km ~
(Signature of properly owner or authorized agent)
Permit Fees:
Date or Payment:
Recelp{ Number:
(Rev, 12/00)
Waiver Fees:
Data of Payment:
Receipt Number:
August 1, 2001
ROBERT C. COWAN, P.E.
CML ENGINEERS
(907) 694-2979
FAX (907) 694-12t 1
MUNICIPALITY OF ANCHORAGE
Development Services Department
P.O. Box 196650
Anchorage, AK. 99519
REFERENCE: Lot 41, Block l, Wynter Park Subdivision #I
It is requested that you issue a permit to upgrade a septic system to serve the existing
three bedroom dwelling on the referenced property.
A test hole was excavated and a percolation test performed on 7/24/01. The approximate
location of the test hole is located on the attached site plan. At the time of excavation, no
water was found. Ground water was monitored and after seven days, water was not found
as shown on the attached soils logs.
We do not anticipate any adverse effects on neighboring wells, septic systems, reserve
areas or drainage patterns by the installation of the proposed septic system. The
construction of this system will not prevent any future development on any of the adjacent
properties.
If you require additional information, please contact us.
Sincerely,
Robert C. Cowan, P.E.
Enclosure
17034 NORTH EAGLE RIVER LOOP" SUITE 204 · EAGLE RNER. ALASKA 9957'7
~..[oT _4!, n[oc~ ~,
~ ' B.J.J. - R.C.C.
rring DESIGN I .
3 SDRU ~ L4s,
SOILS = u.o /SO.FI·
450/0.6 = ;O.FI. REO'O.
DRAINFIEI
8.0' DEEP
LONG (! 0 40', 1 @ 35')
LOT 38
SEPTIC~
LOT
39 r,.(REA
WYNTER PARK S 1
8-8-01 1 OF 1
'LOT 42
CONTRACTOR IS
OSTAJN UTILITY
PRIOR TO ANY
WORK.
SPLIT~ER
PROPOSED
TRENCHEB
I
<1
L"I
~-I
'~1
'-I
FCO
' '" SEP'''~'~'xll~..)
AREA
VALVE
1000 GALLON
TANK (PUMP. CRUSH,
ABANDON AND
LOT 40
0
0
,_-]
ROBERT C. COWAH
CE - 8801
SEPTIC
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 South Bragaw SL
P.O. Box 196650 Ancflomge, AK 99519-6650
www.d.ancho~aae.ak.os
{907) ~43-7904
Soils Log - Percolation Test
Performed For: CZ. IF,~'
Legal Description: Z41:~I; ~,/Y'/Vl-C-~ I'~A-F-.IZ '~/~Township, Range, Section:
· / SIo~e / Site Plan
5-
6-
7-
8-
9-
10-
11-
12-
13-
14-
16-
17-
18-
19-
20-
COMMENTS
I IIl~J~l / I' I-"h
I III-1~. ,b~fH
I I1~'~"1 I / I I II
I I I I I I~-,1~-t-~ II
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT DEPTH?
Depth to Water ARer
Monitoring?
Reading Date Gross Time Net Time Depth lo WaterNet Drop
~o ~ s,, i ~/+
o 0 ~Yz" --
PERCOLATION RATE [~['-
TEST RUN BETWEEN ~"
PERC HOLE DIAMETER
S & $ ENGINEERING
PERFORMEDBY~?o_9.1I=.,~.I.,II,,..~. lm,~nl~.a.dNe..~ I ~_~_. ~]~./~l CERTIFY THAT THIS TES~T W~S
PERFORMED N L~t~%C~[I~[~ ~f~ATE AND ~ UN C PAr GU DEL NES IN EFFECT ON THIS DATE. DATE:
ROBERT C. COWAN. P.E.
CIVIL ENGINEERS
(907) 694-2979
FAX (907) 694-1211
ON-SITE WASTEWATER DISPOSAL SYSTEM
CONSTRUCTION PRACTICES
and
MATERIAL SPECIFICATIONS
REFERENCE: Lot 4 I, Block I, Wynter Park Subdivision # I
August 1, 2001
GENERAL:
The scope of this project includes the verification of the existing 1000 gallon
septic tank, replacement with a 1000 gallon minimum septic tank if required,
and installation of new trenches to serve the existing three bedroom residence
located on the referenced property.
Construction shall be in accordance with the approved site plan and design
drawings, Municipal,permit with any special provisions or conditions, and all
applicable State and Municipal Wastewater Disposal Regulations.
The contractor shall be responsible for obtaining any necessary underground
utility locates.
Unless specifically agreed otherwise, the property owner shall be responsible
for final grading areas subsequently depressed fron{ soil settling.
Contractors installing wastewater disposal systems must be certified by the
Municipal Health Department for system installations. Owners installing their
own systems must also receive prior approval from the Municipal Health
Department.
SEPTIC TANK INSTALLATION:
A septic tank is to be constructed by a certified septic tank manufacturer.
Construction shall include two 4" cleanouts for pumping access.
The septic tank shall be sufficiently bedded to prevent settling or shifting of
the tank.
17034 NORTH EAGLE RIVER LOOP · SUITE 204 * EAGLE FUVER. ALASKA 99577
Page 2
Lot 41, Block 1, Wyntar Perk Subdivision #1
August 1, 2001
All standpipes on the septic tank shall extend a minimum of 12 inches above final grade.
Septic tanks installed with less than 4 ft. ofcover shall be insulated.
A foundation cleanout shall be installed one to four feet from the building foundation. In
the line between the tank and the leachfield there shall be two adjacent cleanouts (unless
an effluent pumping system exists within the septic tank). These cleanouts shall be
located on undisturbed soil not more than 10 ft. from the tank. The first cleanout, in line,
shall be to clean toward the leachfield. The second cleanout shall be to clean toward the
septic tank.
Final grading over the septic tank shall be such that a positive slope exists away from the
septic tank.
ABSORPTION TRENCH]DRAINFIELD INSTALLATION:
Excavate the proposed trench to the dimensions shown on the design. The bottom of the
excavation shall be within 2 inches of level. If the sidewalls of the excavation become
smeared, they must be raked or scratched (ruffed-up) before gravel (sewer rock)
placement.
Once the gravel is installed, the distribution pipe is to be installed level with the
perforations faced downward. Gravel is then to be placed over the dxstnbutmn pipe to
provide a minimum of 2 inches of cover over the pipe.
A silt barrier must be installed between the final gravel layer and the native soil backfill.
Ensure the silt barrier covers the entire gravel surface before placing backfill.
Monitor tubes shall be of four (4) inch diameter, installed approximately in the locations
shown on the design, and extend a minimum of 12 inches above final grade. The portion
ofthe monitoring tube extending through the gravel shall be perforated from the bottom of
the trench to the invert ofthe distribution pipe. This is equivalent to the effective depth of
the gravel as noted on the design.
Backfill over the final gravel layer must not be less than twenty-four (24) inches.
Insulation must be installed when the backfill depth is less than thirty-six (36) inches. The
finish grade over the trench must be mounded to prevent the formation of a depression
afier settling.
Page 3
Lot 41, Block 1, Wynter Park Subdlvlmlon #1
Augumt 1, 2001
MINIMUM MATERIAL SPECIFICATIONS:
4
Any septic tank proposed for installation must be constructed by a Municipal approved
septic tank manufacturer.
The following pipe materials are approved for use in septic system installations in the
Municipality of Anchorage:
Type of Pipe Perforated Solid
Cast Iron Yes Yes
ASTM D3034 (PVC) Yes Yes
ASTM F810 (HDPE) Yes No
ASTM D2662 (ABS) Yes Yes
Use of a type of pipe other than listed above must be approved by the inspecting engineer.
Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical
Company Styrofoam HI or equal).
Septic tank inlets and outlets shall be fitted with watertight couplings (Caulder, Fernco, or
equal).
A permeable nontoxic silt barrier (Typar 3401, Mirafi 140N, or equal) must be installed
between the final leachfield gravel layer and the native soil backfill.
All leachfield gravel (sewer rock) shall be 0.5"-2.5" screened gravel with less than 3%
passing the #200 sieve.
When sand is being used as a filter material, its gradation specifications must conform to
current M.O.A. or D.E.C. requirements, which ever requirement applies.
INSPECTIONS:
Typically there will be a minimum of three (3) inspections required during the installation of the
wastewater disposal system. These inspections will occur as follows:
Page 4
Lot 41, Block 1, Wynter Park Subdivision #1
August 1, 2001
The first inspection must be conducted after the excavation of ditches, pits,
trenches, or beds and before the installation of any gravel. A septic tank may be
set in place, but may not be backfilled before this inspection.
The second inspection must be conducted after the placement of the silt barrier,
gravel, distribution lines, standpipes, cleanouts, and insulation, but before the
placement of any other backfill.
3. The final inspection is to occur upon final grading of the property.
Often there will be more than these 3 inspections required. Especially with the installation of
multiple trenches, sand filters, pressurized distribution systems, etc. Thus, the inspecting engineer
is to be contacted at least 24 hours prior to the start of construction. If necessary, a pre-
construction meeting will take place on-site. The inspecting engineer will not coordinate, direct or
control in any way the contractors activities.
The owner shall contract with the contractor to perform the work outlined in these specifications
and plans and in accordance with the attached M.O.A. permit. There will be no contractual
arrangement existing between the contractor and S & S Engineering. S & S Engineering shall be
the owners representative and will inspect the work as stated above to document the contractors
activities. Final acceptance of the contractors work rests with the owner and the M.O.A.
S & S Engineering shall have no liability to the owner or to others for acts or omissions of the
contractor or any other persons performing work on this project or the failure of the contractor to
carry out the work in accordance with these construction documents. S & S Engineering's
inspecting engineer will not be responsible for the construction means, methods, techniques,
sequence, procedures or the safety precautions incident to this project.
CONTRACTOR / INSTALLER
MUNICIPALITY OF ANCHORAGE
· DEPARTIVIENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchora§e, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
N~AME PHONE ~EW
MAILING ADDRESS
LOCATION -- ~, OF ~EDROOMS
~ N Liq. capacity in gallons Inside length Width Liquid depth
~ ~ DISTANCE TO: Well ' Dwelling PERMIT NO.
~ Foundation Nearest lot line
7
Len h of each line
-~ ~ ~[[,[2, Total len~h~f, lines Trench widd~inches~ Distance between lines
~ ~ ~ Top of tile to finish grade ' / [ Material beneath tile
effective
absorption
Length Width Depth P~RMIT NO,
DISTANCE TO:
~ s ,De~t~.~f~ ~} Driller Distance to lot line PERMIT NQ,
OTHER ................
PiPE MATERIALS ~ '~
SOIL TEST RATING --¢ ~
INSTALLER
REMARKS ~
APPROVED DATE LEGAl_
72-013 (Rev. 3/78)
PERMIT NO. ( 8210t? )
RPPLICRNT
LOCRTION
LEGAL
~"~IL.IN I C I ~-"FIIL I -r"-~' 6'iF: ~::t~'-,tl]:lj '~RI:~GE
DEF'RRTMEMT HEFILTH FIND ENVIRONMENTRL .:OTECTION
825 "L" STREET, RNCFIORRGE., BK. 9950:1.
264-4720
"~--; E ~-.! EE R P E R £-111
RFIYMOND PELLITIER
L41 Bi NYTER PFIRK
67~0 E t6TH FIVE
268-8725
LOT SIZE 999999 SQURRE FEET
TYPE OF SOIL FIBSORPTION SYSTEM IS: TRENCH
MRXIMUM NUMBER OF BEDROOMS
SOIL RATING
THE REt.~UIRED SIZE OF THE SOIL FIBSORPTION SYSTEM IS:
['., E P-IF H == 8 L E l'",,l .G 1-' H--- 6 ~..':;, 6f~: R'-," EEL IDEF'TH==
THE LENOTFI DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR I}RFIINFIELD.
TNE DEPTH OF FI TRENCH OR PIT IS TWE DISTFINCE BETWEEN THE SURFACE OF ]'HE
GROUND FIND THE BOTTOM OF THE EXCRVFITION (IN FEET).
TNERE IS NO SET WIDTI-I FOR TRENCNES.
TME GRAVEL DEPTH 'IS THE MINIMUM DEPTH OF GRFIYEL B!ETWEEN THE OUTFFII_L PIPE
FIND THE BOTTOM OF THE ENCFIVRTION ,.'.IN FEET).
PERMIT FIPPLICRNT HFIS THE: RESPONSIBILITY TO INFORM THIS DEF'RRTMENT DURING THE
INSTRLLFITION INSPECTIONS OF' FINY WELLS FIDJFICENT TO THIS PROPERTY FIND THE
NUMBER OF RESIDENCES THRT THE WELL WILL SERVE.
BFICKI--ILLING OF ANY SYSTEM NITHOUT FINFIL IN'=;PECTION FIND RPPROVRL BY THIS
DEPRRTMENT WILL BE SUBJECT TO PROSEC.:UTION.
MINIMUM DISTFINCE BETNEEN R WELL FIND RNY ON-SITE SEWAGE DISPOSAL SYSTEM IS
±00 FEET FOR FI PRI',,,'RTE NELL. OR ±50 TO 200 FEET FROM FI PIJBLIC NELL DEPENDING
UPON THE TYPE OF PUBLIC NELL
MINIMUM DI'=;TRNr'-:E FROM FI PRIVRTE WELL TO R F'RIVi=ITE SEWER LINE IS 25 FEET RN[:,
TO FI COMMUNITY SEWER. LINE IS 75 FEET.
OTHER REQUIREMENTS MRY RPPLY. SPECIFICRTIONS FIND CONSTRUCTION [:,IRGRRf'IS FIRE:
RVFIILFIBLE TO INSURE PROPER INSTRLLRTION.
I CERTIFY THFIT
±: I BM FRMILIRR WITN THE REQtJIREMENTS FOR ON-SITE SEWERS RND WELLS FIS SET
FORTFI BY THE MUNICIPFILITY OF ANCHORAGE,
2: I MILL INSTFILL THE SYSTEM IN RCCORDFINCE WITH THE CODES.
]:: I UNDERSTRND THFIT THIF' ON-SITE SEWER SYSTEM MFIY RE6,~UIRE ENLARGEMENT IF TFIE
RESIDENCE IS REMODELED TO INCLUDE MORE THAN ]: BEDROOMS.
SIGNED: ..................................................
FIPPLI CFINT RFIYMOND PELLITIER
......... TF ........... F .................. .... r
V4. 0
~ [~ ~ '~'F 14~TH FOR T~
L
SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L, Street, Anchorage, Alaska 99501 264-4720
SOILS LOG -- PERCOLATION TEST
PERCOLATION
TEST
PERFORMED FOR:._~
LEGAL DESCRIPTION:
2
3
4-
5-
g-
~0-
13-
14-
15-
16-
17-
18-
19-
20-
COMMENTS
~RV~L.
SLOPE SITE PLAN
ENCOUNTERED?
O
P
E
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
ReadingDate Time Time Water Drop
s' ~, ~.,oo ~o~,',, ~ ~ ~"~
PERCOLATION RATE //'~' ~ (minutes/inch)
TEST RUN BETWEEN ~ , FT ANO ~ FT
__CERTIFIED BY: DATE:
Municipality of Anchorage
Development serVices Department
Building Safety Division
On-Site Water and Wastewater Program
4700 South Bragaw SL
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUT,HORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I~D~' 0 ~' I -/4 q I --I ~l_
Expiration Date: I O - / ~"- O .O-
1. GENERAL INFORMATION
C~)mpletelegaldescription Lot. /,1; Block l; T.,Tynter ?ark $/D
'-L~cation (site address or directions) 21138 Lookout: circle, Chugtak,
AK 99567
".. Current Property 6wner(s) Cliff ]{ansen Day phone 253-857-2694
Mailing address 15901 121 Ave. KPN Gig~; Earor, WA 98329
Lending agency
Day phone
Mailing address
Real Estate Agent
Day phone
Mailing Address
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class ~
Public Water System
Well
TYPE OF WASTEWATER DISPOSAL:
[] Individual On-site []
[]~ Individual Holding tank
Communi,~ On-site
[] Public Sewer
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of
titIe (except between spouses) for properties served by a single family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are
valid for 90 days from the date of issue for properties served by a pdvate or Class C well and may be reissued with
new water sample results less than 30 days old. (Certificates may be reissued for a period of up to one year with
valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public
water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional
engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verity that my investigation,
based on procedures outlined in the Health Authority Approval Guidelines for this epplication, shows that the
on-site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of
bedrooms and type of structure indicated herein. I further verity that based on the information obtained from the
Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is(are) in compliance with all applicable Municipal and State cedes, ordinances,
and regulations in affect at the time of installation.
Name of Firm
Address
Engineer's Printed Name
5. DSD SIGNATURE
t,/'"" Approved for
Disapproved.
$ & $ ENGINEERING
Eagle River, Alaska 99577
bedrooms.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
Attachments:
HAA Checklist
Septic System Adviso~
Well Flow Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date:
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 South Brogaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anctmrage.ak.us
(~0~) 343-?g04
Legal Description:
A. WELL DATA
we,~ ~
Date completed
Total depth
HEALTH AuTHoRITY APPROVAL CHECKLIST
IfA.
~ seal fi/N)
Cased to
:ROM WELL LOG '
Date of test
Static water I
Well g.p.m.
WATER RESULTS:
colonies/100 mi.
Nitrate ' mg./I.
co, ec~d by:
Well Log (Y/N).
W*~,s properly protected (Y/N)
Casing height (above ground)
AT INSPECTION
in.
g.p.m.
Other bacteria
colonies/100 mi.
B. SEPTIC/HOLDING TANK DATA
Tank
Type/Mate.rial
Tanksize /~ gal. NumberofCompaflments..~
Foundation ~eanout (Y./N)'~ Depressio~ over tank (Y/N) /~'
Date of pumping ' "' ~'~""~J Pumper
C. ABSORPTION FIELD DATA
Date instelle~l~ .~. ~/"BOi' ratin~ ~/bdrm} 0-_(,, System type
Length ..~lr: ~.;. It'. W'~th 4 ~. ~' ff. Gravel below pipe ~' ft.
Tatal depth/O ft. Eft. absorption area,'".~:~._ft2 Monitoring tube, / Depression over field
Date of adequacy test /~ ~ ~s/Fail). For bedrooms
Fluid depth in absorption field be./~_~'~-. . in. . Water added gal. New depth in.
Elapsed Time: min./ Final flui. ~.d__e~th_' . in. Absorption rate >= g.p.d.
Any rejuvenation tre~nt (past 12 mo.) (Y/N & type) If yes, give date
D. UFT ~FATION
Date installed
Size in gallons
/
'Pump on' lovel at 7/_in.
/
Datum
!
E. SEPARATION DISTANCES
'Pump off' level et
Cycles tested
Manhole/Access (Y/N)
High water alarm level et
Meets ~lan~ & cJrcuit ~quiraments?
Septic tank/lift station on lot ,/ On adjacent lots
field onlot/ * ' Onadjacentlots
Absorption
/
Public sewer main / Public sewer manhole/cleanout
Sewer/septic se/ce line. Holding tank
SEPARATION DISTANCES FROM SEPTIC/I'[CIL'I~ TANK ON LOT TO:
Building foundation ~ /./- Property line ~' ~ Absorption field
I
Watermain /C~ /4-- Water se~ce line /~:? -/- Surface water
Wells on adjacent lots ~
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Propertyline )O / Bulldlngfoundatlon /O ~- Watermain
Water Sel~ce line /c~ ' '~'
Sun'ace water /
/
Curtain drain,/~/V~' ~V~/~/ Wells on adjacent lots ~
F. COMMENTS
Driveway, parking~ehide storage
In.
G. ENGINEER's CERTIFICATION
I certify that I have determined through field inspections end
review of Municipal records that the above sys~ms are in
conformance wfth MOA HAA guidelines in effecf on this date.
Engineer's Printed Name /~0,~/~,~'~' C'.
Data J O /~l /O ~/
HAA Fee $
Date of Payment
Receipt Number
(Rev. 12/00)
0 11~7 ~
Waiver Fee $
Date of Payment
Receipt Number
MUNICIPALITY OK ANCHOt~AGE
DIVerSION OF ENVIRONMENTAL HE/AL2H
DEP/~ME~ OF ~L'I~ ,~ND ENVIR(~MENT~L PR~FECTION
APPLICATI~ ~R ~]q ~J~ORITY ~PROVAL CERTIFI~TE
1. ~mral Ii]fot~m~tion Application Date
(a) legal Des¢,~iptioo (incl3.~de lot~ block, subdivision, m~.ction, to.~%ship, range)
Locat~ion (add~ess or directions)
2o ]~ of ~siden~m
Nu~.r of ~edro(nns
3. Water Sup~pjf.
Individual Well
Othe~ (¢tescribe)
Note: If ccrarunity well system~ must have v~itten con:l:'irnvntion ff~n the State
[)epa~dnment of ~vironm~ntal Conservation attesting to tka lega].itt~ and status.
Ils the %911 adequate fo~ the nt~r of ~dr~ st~cified in this
4,
Is ~e wastewater dis~sal system adequate f~ the numar of ~dr~ )
[Page 1 of 2]
2-15-84
I certify that/~I-q~v~ cl~e. cked, ver!.fied, Jt conformed to all ~A ~ (~.~11~s i~
effect on th~< dat~--~ct~on.
S ig~ ~.~.~~/~~//~ Date ~- / ~/~' ~
N~ of ~il~ ~lephor~
Add~.ess
Signed by
Da te
(5~GI EER SEAL)
Conditional
5]~e Municipality of Anchorage Departnrsnt of Health and Environn~ntal t~,otection dc~s
not guarantee the continued satisfactory psrfomm3nce of the water supply and/or the
wastevmter disposal system. This approval indicates that, as of the validation date
shown abo~, ba~d on the data and inforn~tion furnished bf an el~i~,~er registered
the State cf Alaska, the ~ter supply and wastewater disposal system is safe ar~l func-
tional for the number of hedrcc~ss ~d type of structure indicated.
( D~IEP S~%L)
7. Mail th~ HAA, to t~?follc~ing ~Jdress:
KB2/d5/s
[Page 2 of 2]
2-15-84
WEIJ~ DATA
Well Classification_
Well Log P~esent (Y/N)
Tot:al De pth~j
Static Wate~ Level
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL ([{AA)
CHECKLIST - FEBRUARY 1984
Cased to
Casing Height Above G~.ound _ . Sanitary Seal on Casing (Y/N)
ElectriTal Wiring in Conduit (Y~/~--/~ _~__._~u_ Depression A~ound ~llhead (Y_Y_Y_Y_Y_Y_Y_Y_Y_~N)
Sep~.s~ atl°n Dis .tanaes f~om We 11 ://~ //~-- ...
To ptic/Holdlng Ta~ on Lot ~
To Nearest Edge of Absorption Field on/~ot__'__ ; On Adjoining Lots
To Nearest Public Sewe.~ Line To Nearest Public Sewer
Cleanout/Manhole To Nearest Sewer Service Lil~ on Lot
Wate~ Sarap~e Collected By ; Date
Wate~ Sample Test Results
Cc~rents
B. SEPTIC~TANK DATA
Date Instal~ - ~- Si~ No.
Standpim~ (~ / ~i=-t:[ght Caps/~ Foundation Clea~out ~..
~ession o~ Ta~ .~ ~te ~t ~d _.~_
P~ing~intenan~ Con~a~ ~ File ~~_; for _ __
Holding Ta~ High-Water Ala~ ~~~a~y Holdi~ Ta~k ~rmit
Sep~ation Distant% ~-~pt~ding ~nk: /
' ~ ~o S~e~, Pond, ~e, ~ Majo~ ~aina~
TO Water ~Se~vi~ Li~ . '
Co~
[Page 1 of 2] 2-15~84
Ce
ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed /0 /7./~ Z-
Width of Field ~ ~
Type of System Design
Length of Field ~ 6' /
Depth of Field '~ ~-- !
Gravel Bed Thickness
Square Feet of Absorption/~ea I.~'--~_-~3 Standpipes P~esent
~p~ession ove~ Field (C~ ~te of ~st A~a~ ~st
Results of ~st A~a~ ~st ~ ./ ~
Sep~ation Distan~ f~ ~sorption Field:
· o /
To Buildi~ Foun~tion ~ To Existing or ~ndo~d System
Lot /~ }"~ ; ~ Adjoining ~ts .~o 't
To Wate~-~rvi~ Line ~ To Cut~(if pre~nt)
TO Stre~ond~ke/~ Majo~ ~aina~ C~se ~' /9'
TO ~iveway, Parki~ ~ea, ~ Vehicle St~a~ ~ea ~O /
Ccnu~nts
D. LIF~ STATION
Date Installed Din~nsions
Size in Gallons at~/////~ Manhole/Access ( Y/N )
"Pump On" Level at "Pump Off" Level at
High Water Alarm Level Vent (Y/N__) _
Tested for ! Pumping Cycles during Adequacy Test.
Electrical Codes(Y/N)
Meets MOA
Conluents
I o~rtify th~av~, checked,
.on the
MOA No,
. Check Permitted Bedroom Rating Against HAA Request
verified, c~ conformed to all MOA HAA Guidelines in effect
. [Page 2 of 2]
2-15-84
BILL SHEFFIELD, GOVERNOR
SOUTHCENTI~L REGIONAL OFFICE
437 "E" ST~ET, SUITE 200 274-2533
ANCHO~GE, ~AS~ 99501
To Whom It May Concern:
---- ~i...~__ Water System is in compl-i~g-~ wi--~ ih~ Stat------~? Drinking
Water Regulations.
Sincerely,